Sex-Specific Influence of Quadriceps Weakness on Worsening Patellofemoral and Tibiofemoral Cartilage Damage: A Prospective Cohort Study

Sex differences in osteoarthritis prevalence, pain perception, physical function and therapeutics

OBJECTIVE

Women have a higher prevalence of osteoarthritis (OA) and worse clinical courses than men. However, the underlying factors and therapeutic outcomes of these sex-specific differences are incompletely researched. This review examines the current state of knowledge regarding sex differences in OA prevalence, risk factors, pain severity, functional outcomes, and use and response to therapeutics.

METHODS

PubMed database was used with the title keyword combinations "{gender OR sex} AND osteoarthritis" plus additional manual search of the included papers for pertinent references, yielding 212 references. Additional references were added and 343 were reviewed for appropriateness.

RESULTS

Globally, women account for 60% of people with osteoarthritis, with a greater difference after age 40. The higher risk for women may be due to differences in joint anatomy, alignment, muscle strength, hormonal influences, obesity, and/or genetics. At the same radiographic severity, women have greater pain severity than men, which may be explained by biologically distinct pain pathways, differential activation of central pain pathways, differences in pain sensitivity, perception, reporting, and coping strategies. Women have greater limitations of physical function and performance than men independent of BMI, OA severity, injury history, and amount of weekly exercise. Women also have greater use of analgesic medications than men but less use of arthroplasty and poorer prognosis after surgical interventions.

CONCLUSIONS

The recognition of sex differences in OA manifestations and management could guide tailoring of sex-specific treatment protocols, and analysis of sex as a biological variable in future research would enhance development of precision medicine.

Sexual dimorphism in peri-articular tissue anatomy - More keys to understanding sex-differences in osteoarthritis?

Objective

Osteoarthritis prevalence differs between women and men; whether this is the result of differences in pre-morbid articular or peri-articular anatomical morphotypes remains enigmatic. Albeit sex within humans cannot be reduced to female/male, this review focusses to the sexual dimorphism of peri-articular tissues, given lack of literature on non-binary subjects.

Methods

Based on a Pubmed search and input from experts, we selected relevant articles based on the authors' judgement of relevance, interest, and quality; no "hard" bibliometric measures were used to evaluate the quality or importance of the work. Emphasis was on clinical studies, with most (imaging) data being available for the knee and thigh.

Results

The literature on sexual dimorphism of peri-articular tissues is reviewed: 1) bone size/shape, 2) subchondral/subarticular bone, 3) synovial membrane and infra-patellar fad-pad (IPFP), 4) muscle/adipose tissue, and 5) peri-articular tissue response to treatment.

Conclusions

Relevant sex-specific differences exist for 3D bone shape and IPFP size, even after normalization to body weight. Presence of effusion- and Hoffa-synovitis is associated with greater risk of incident knee osteoarthritis in overweight women, but not in men. When normalized to bone size, men exhibit greater muscle, and women greater adipose tissue measures relative to the opposite sex. Reduced thigh muscle specific strength is associated with incident knee osteoarthritis and knee replacement in women, but not in men. These observations may explain why women with muscle strength deficits have a poorer prognosis than men with similar deficits. A "one size/sex fits all" approach must be urgently abandoned in osteoarthritis research.

There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders

BACKGROUND

Impairments in hamstring strength, flexibility, and morphology have been associated with altered knee biomechanics, pain, and function. Determining the presence of these impairments in individuals with gradual-onset knee disorders is important and may indicate targets for assessment and rehabilitation. This systematic review aimed to synthesize the literature to determine the presence of impairments in hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders.

METHODS

Five databases (MEDLINE, Embase, CINAHL, SPORTDiscus, and Web of Science) were searched from inception to September 2022. Only studies comparing hamstring outcomes (e.g., strength, flexibility, and/or morphology) between individuals with gradual-onset knee disorders and their unaffected limbs or pain-free controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation, and evidence gap maps were created.

RESULTS

Seventy-nine studies across 4 different gradual-onset knee disorders (i.e., knee osteoarthritis (OA), patellofemoral pain (PFP), chondromalacia patellae, and patellar tendinopathy) were included. Individuals with knee OA presented with reduced hamstring strength compared to pain-free controls during isometric (standard mean difference (SMD) = -0.76, 95% confidence interval (95%CI) : -1.32 to -0.21) and concentric contractions (SMD = -0.97, 95%CI : -1.49 to -0.45). Individuals with PFP presented with reduced hamstring strength compared to pain-free controls during isometric (SMD = -0.48, 95%CI : -0.82 to -0.14), concentric (SMD = -1.07, 95%CI : -2.08 to -0.06), and eccentric contractions (SMD = -0.59, 95%CI : -0.97 to -0.21). No differences were observed in individuals with patellar tendinopathy. Individuals with PFP presented with reduced hamstring flexibility when compared to pain-free controls (SMD = -0.76, 95%CI : -1.15 to -0.36). Evidence gap maps identified insufficient evidence for chondromalacia patellae and hamstring morphology across all gradual-onset knee disorders.

CONCLUSION

Our findings suggest that assessing and targeting impairments in hamstring strength and flexibility during rehabilitation may be recommended for individuals with knee OA or PFP.

The effect of high-intensity laser therapy on pain and lower extremity function in patellofemoral pain syndrome: a single-blind randomized controlled trial

Patellofemoral pain syndrome (PFPS) is a set of symptoms that negatively affect the daily life activities of the individual, leading to functional disability and significant loss of labor, especially in young adults. PFPS is usually due to weakness of the vastus medialis obliquus (VMO) resulting in abnormal patellar tracking and pain. Our study aims to compare the efficacy of high-intensity laser therapy (HILT) on pain and lower extremity function in the treatment of PFPS with different electrophysical agents (EPAs). The study was designed as a single-blind randomized controlled trial. Forty-five people with PFPS (aged 25-45 years) were included in the study. The patients were randomly divided into three groups and a total of ten sessions of treatment were administered to all three groups for 2 weeks, 5 days a week. High-intensity laser (HILT) and exercise program were applied to group 1. Ultrasound (US), transcutaneous electrical nerve stimulation (TENS), and exercise program were applied to group 2. In group 3, US, interferential current (IFC), and exercise program were applied. Both groups underwent three evaluations: pre-treatment, post-treatment, and 12 weeks after treatment. Outcome measures included the visual analog scale for pain severity (VAS), knee flexion range of motion (FROM), Q angle, pain threshold, muscle strength of quadriceps and hamstring, Kujala patellofemoral scoring, lower extremity functional scale (LEFS), and Timed Up and Go Test (TUG). The ANOVA was used for comparing the data of the groups, and two-way repeated measure ANOVA was used to compare at the pre-post and post-intervention 3rd month. The LSD and Bonferroni post hoc tests were also used to identify the between-group differences. Groups 2 and 3 were statistically effective in pain and functionality (p < 0.05). Group 1 was found to be statistically more effective than other groups in reducing pain (95% confidence interval (CI), 0.000/0.000; p = 0.000), increasing knee flexion angle (95% CI, 127.524/135.809; p = 0.000), and increasing lower extremity function (95% CI, 75.970/79.362; p = 0.000). This study indicated that high-intensity laser therapy was found to be a more effective method in the treatment of patellofemoral pain syndrome after 3 months of follow-up compared to US-TENS combination and US-interferential current combination treatments. Also, HILT can be used as an effective method in combination with an appropriate exercise program including vastus medialis strengthening to reduce pain and increase functionality in the patients with PFPS.

Sex does not influence the long-term outcome of matrix-assisted autologous chondrocyte transplantation

PURPOSE

Regenerative techniques for articular cartilage lesions demonstrated heterogeneous clinical results. Several factors may influence the outcome, with sex being one of the most debated. This study aimed at quantifying the long-term influence of sex on the clinical outcome obtained with a regenerative procedure for knee chondral lesions.

METHODS

Matrix-assisted autologous chondrocyte transplantation (MACT) was used to treat 235 knees which were prospectively evaluated with the International Knee Documentation Committee (IKDC), EuroQol visual analogue scale, and Tegner scores at 14-year mean follow-up. A multilevel analysis was performed with the IKDC subjective scores standardised according to the age/sex category of each patient and/or the selection of a match-paired subgroup to compare homogeneous men and women patients.

RESULTS

At 14 years, men and women showed a failure rate of 10.7% and 28.8%, respectively (p < 0.0005). An overall improvement was observed in both sexes. Women had more patellar lesions and men more condylar lesions (p = 0.001), and the latter also presented a higher preinjury activity level (p < 0.0005). Men had significantly higher IKDC subjective scores at all follow-ups (at 14 years: 77.2 ± 18.9 vs. 62.8 ± 23.1; p < 0.0005). However, the analysis of homogeneous match-paired populations of men and women, with standardised IKDC subjective scores, showed no differences between men and women (at 14 years: -1.6 ± 1.7 vs. -1.9 ± 1.6).

CONCLUSION

Men and women treated with MACT for knee chondral lesions presented a significant improvement and stable long-term results. When both sexes are compared with homogeneous match-paired groups, they have similar results over time. However, women present more often unfavourable lesion patterns, which proved more challenging in terms of long-term outcome after MACT.

LEVEL OF EVIDENCE

Level II.

Hip Abductor Weakness and Its Association With New or Worsened Knee Pain: Data From the Multicenter Osteoarthritis Study

OBJECTIVE

Hip abductors, important for controlling pelvic and femoral orientation during gait, may affect knee pain. Our objective was to evaluate the relation of hip abductor strength to worsened or new-onset frequent knee pain. Given previously noted associations of knee extensor strength with osteoarthritis in women, we performed sex-specific analyses.

METHODS

We used data from the Multicenter Osteoarthritis study. Hip abductor and knee extensor strength was measured. Knee pain was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and a question about frequent knee pain at baseline (144-month visit), and 8, 16, and 24 months thereafter. Knee pain outcomes were worsened knee pain (2-point increase in WOMAC pain) and incident frequent knee pain (answering yes to the frequent knee pain question among those without frequent knee pain at baseline). Leg-specific analyses tested hip abductor strength as a risk factor for worsened and new frequent knee pain, adjusting for potential covariates. Additionally, we stratified by knee extensor strength (high versus low).

RESULTS

Among women, compared to the highest quartile of hip abductor strength, the lowest quartile had 1.7 (95% confidence interval [95% CI] 1.1-2.6) times the odds of worsened knee pain; significant associations were limited to women with high knee extensor strength (odds ratio 2.0 [95% CI 1.1-3.5]). We found no relation of abductor strength to worsening knee pain in men or with incident frequent knee pain in men or women.

CONCLUSION

Hip abductor weakness was associated with worsening knee pain in women with strong knee extensors, but not with incident frequent knee pain in men or women. Knee extensor strength may be necessary, but not sufficient, to prevent pain worsening.

Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies

OBJECTIVE

To evaluate the sex-specific association between low knee extensor and flexor muscle strength and the risk of knee structural worsening.

MATERIALS AND METHODS

Systematic searches in five databases identified longitudinal studies (≥ 1 year follow-up) reporting an association between knee extensor or flexor strength and structural decline in individuals with, or at risk of, knee osteoarthritis. Results were pooled for tibiofemoral and patellofemoral osteoarthritis worsening (and stratified by sex/gender where possible) using a random-effects meta-analysis estimating the risk ratio and 95% confidence interval or a best-evidence synthesis. Risk of bias and overall certainty of evidence were assessed.

RESULTS

Fourteen studies were included with participants (mean age 27-72 years) with osteoarthritis (n = 8), at risk of osteoarthritis (n = 3), or a combination with, or at risk of, osteoarthritis (n = 3). Low knee extensor strength was associated with an increased risk of worsening tibiofemoral (12 studies: RR 1.18, 95% CI 1.04 to 1.35) and patellofemoral osteoarthritis (4 studies: RR 1.62, 95% CI 1.01 to 2.61). Significant associations between low knee extensor strength and worsening tibiofemoral osteoarthritis were observed for women (4 studies: RR 1.25, 95% CI 1.04 to 1.51) but not men (4 studies: RR 1.10, 95% CI 0.87 to 1.39). Low knee flexor strength increased the risk of worsening tibiofemoral osteoarthritis (5 studies: RR 1.16, 95% CI 1.07 to 1.26). Ten studies were high risk of bias, and all estimates were graded as very low certainty of evidence.

CONCLUSION

Low knee extensor and flexor strength increased the risk of worsening tibiofemoral osteoarthritis. Low knee extensor strength increased the risk of worsening patellofemoral osteoarthritis. The relationship between low knee extensor strength and worsening tibiofemoral osteoarthritis may be modified by sex/gender.

Persistence of neuromuscular activation deficit in the lower limb at 3-years of follow-up after ACL reconstruction surgery

BACKGROUND

Almost all patients experience neuromuscular disorders of the quadriceps after knee trauma or surgery such as anterior cruciate ligament (ACL) reconstruction. This phenomenon is described in literature as arthrogenic muscle inhibition (AMI). It can be detrimental to patients and cause complications. However, few studies have evaluated the long-term persistence of deficits arising from this, following ACL reconstruction.

PURPOSE

By comparing neuromuscular activation in the lower limb after ACL reconstruction with the unaffected lower limb, after more than 3-years of follow-up, this study aimed to evaluate the possible persistence of long-term deficits after surgery.

METHODS

Fifty-one patients who underwent ACL reconstruction in 2018 were included in the study, with a minimum follow-up of 3 years. The neuromuscular activation deficit was assessed using the Biarritz Activation Score-Knee (BAS-K), whose intra- and inter-observer reproducibility was also evaluated. The ACL-RSI, KOOS, SANE Leg, Tegner and IKDC scores were also evaluated.

RESULTS

The mean BAS-K score of the knee that underwent surgery was 21.8/50 versus 37.9/50 in the healthy knee (p < 0.05). The SANE leg score was 76.8/100 versus 97.6/100 (p < 0.05). The mean IKDC was 84.17 (±12.7). The mean KOOS was 86.2 (±9.2). The mean ACL-RSI was 70 (±7.9) and the Tegner score was 6.3 (±1.2). Intra- and inter-observer reproducibility was satisfactory for the BAS-K score.

CONCLUSION

We found that the neuromuscular activation deficit was high (roughly 42%) at more than 3-years of follow-up after ACL reconstruction. The deficit is not limited to the quadriceps and affects the whole limb. Our findings highlight the need for appropriate rehabilitation after ACL surgery, targeting the corticospinal level in particular.

LEVEL OF EVIDENCE III

prognostic retrospective case-control study.

Radiological and clinical outcomes of concurrent hamstring stretching with quadriceps strengthening in patients with knee osteoarthritis: A randomized clinical trial

BACKGROUND: Hamstring shortening altered joint reaction forces during activities of daily living (ADL), causing knee pain. Moreover, weak quadriceps may negatively distribute the compressive and shear forces at the knee joint. PURPOSE: The study examined the effect of adding hamstring stretching to quadriceps strengthening exercises on joint space narrowing (JSN), medial joint space width (mJSW), and physical abilities in patients with knee osteoarthritis (KOA). METHODS: A total of 42 osteoarthritis patients, aged from 50 to 65 years, were randomized and assigned into 2 groups: the study and the control groups. Quadriceps strengthening exercises were given to both groups, while static hamstring stretching was applied to only the study group. Patients of both groups were screened with a weight-bearing x-ray beam to investigate the JSN, mJSW, and functional abilities measured in the WOMAC scale. The Outcomes were evaluated at the baseline and immediately after 6 weeks of treatment. RESULTS: The mJSW improved in the study group (p< 0.001) compared to the control group (p= 0.07). The OARSI JSN was enhanced significantly in both groups, but in favor of the study group (p< 0.001) over the control group (p= 0.046). Both MVIC and total score of WOMAC were significantly improved in both groups (p< 0.001). CONCLUSION: Adding static hamstring stretching to quadriceps strengthening exercises provided a substantial effect on mJSW, JSN, and functional abilities in KOA patients.

Quadriceps strength is negatively associated with knee joint structural abnormalities-data from osteoarthritis initiative

OBJECTIVE

The aim of this study was to explore the longitudinal associations between baseline quadriceps strength and knee joint structural abnormalities in knee osteoarthritis (KOA).

METHODS

This study is a longitudinally observational study based on Osteoarthritis Initiative (OAI) cohort, including men and women aged 45-79. Quadriceps strength was measured by isometric knee extension testing at baseline. Knee joint structural abnormalities, including cartilage damage, bone marrow lesions (BMLs), effusion-synovitis and Hoffa-synovitis, were evaluated by Magnetic Resonance Imaging Osteoarthritis Knee Score (MOAKS) at baseline and 1-year follow-up. Generalized estimating equations were employed to examine the associations between quadriceps strength and knee structural abnormalities. All analyses were stratified by sex.

RESULTS

One thousand three hundred thirty-eight participants (523 men and 815 women) with a mean age of 61.8 years and a mean BMI of 29.4 kg/m² were included in this study. For men, no significantly longitudinal association of quadriceps strength with structural abnormalities was detected. In contrast, quadriceps strength was significantly and negatively associated with changes in cartilage damage and BMLs in lateral patellofemoral joint (PFJ) (cartilage damage: OR: 0.91, 95% CI 0.84 to 0.99, P = 0.023; BMLs: OR: 0.85, 95% CI 0.74 to 0.96, P = 0.011) and effusion-synovitis (OR = 0.88, 95% CI 0.78 to 0.99, P = 0.045) among females longitudinally. Higher quadriceps strength was significantly associated with less progression of lateral PFJ cartilage damage, BMLs and effusion-synovitis in females.

CONCLUSIONS

Higher quadriceps strength was associated with changes in cartilage damage and BMLs within the lateral PFJ and effusion-synovitis among females, suggesting the potential protective role of quadriceps strength on joint structures in women.

Biomechanical characteristics and muscle function in individuals with patellofemoral osteoarthritis: A systematic review of cross-sectional studies

BACKGROUND

Our objective was to investigate kinematic and kinetic characteristics and changes in muscle function in individuals with patellofemoral osteoarthritis compared to healthy individuals.

METHODS

Searches were performed of the Medline, Embase, Web of Science, The Cochrane Library, LILACS, and SciELO databases until May of 2022 for observational studies comparing individuals with patellofemoral osteoarthritis to a control group. The PRISMA guidelines and recommendations of the Cochrane Collaboration were followed. The GRADE approach was used to analyze and synthesize the level of evidence.

FINDINGS

Fourteen studies were included, involving a total of 594 participants (360 with patellofemoral osteoarthritis and 234 controls). The level of evidence for pelvis, hip adduction and knee abduction angles at 45° of knee flexion during the single-leg squat, and knee flexion angle during the task of walking was very low. Regarding muscle strength, the level of evidence for isometric strength of the hip abductors, extensors and external rotators, and concentric strength of the knee extensors and flexors was very low. It was not possible to synthesize any type of evidence for kinetic, electromyography, or muscle volume variables.

INTERPRETATION

The level of evidence was very low for all synthesized evidence for kinematic and muscle strength variables. However, individuals with patellofemoral osteoarthritis have lower isometric strength of the hip abductor muscles. Further studies with adequate adjustment for confounding factors, such as the non-inclusion of individuals with osteoarthritis in the tibiofemoral compartment concomitant to patellofemoral osteoarthritis, are needed to gain a better understanding of the clinical characteristics of patellofemoral osteoarthritis.

Anterior Knee Pain: State of the Art

Anterior knee pain (AKP) is one of the most common conditions to bring active young patients to a sports injury clinic. It is a heterogeneous condition related to multiple causative factors. Compared to the general population, there appears to be a higher risk of development of patellofemoral osteoarthritis in patients with AKP. AKP can be detrimental to the patient’s quality of life and, in the larger context, significantly burdens the economy with high healthcare costs. This study aims to present a comprehensive evaluation of AKP to improve clinical daily practice. The causes of AKP can be traced not only to structures within and around the knee, but also to factors outside the knee, such as limb malalignment, weakness of specific hip muscle groups, and core and ligamentous laxity. Hence, AKP warrants a pointed evaluation of history and thorough clinical examination, complemented with relevant radiological investigations to identify its origin in the knee and its cause. Conservative management of the condition achieves good results in a majority of patients with AKP. Surgical management becomes necessary only when it is deemed to provide benefit—when the patient has well-characterized structural abnormalities of the knee or limb that correlate with the AKP clinically or in situations where the patient does not obtain significant or sustained relief from symptoms. AKP has a multifactorial etiology. The treatment strategy must be individualized to the patient based on the patient profile and specific cause identified. Hence, treatment of AKP warrants a pointed evaluation of history and thorough clinical examination complemented with relevant radiological investigations to identify the condition’s origin and its cause. A holistic approach focused on the patient as a whole will ensure a good clinical outcome, as much as a focus on the joint as the therapeutic target.

Muscle activation, strength, and volume in people with patellofemoral osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review investigated whether people with patellofemoral osteoarthritis (PFOA) have muscle strength, volume, and activation around the hip and knee that is different from asymptomatic controls.

METHODS

Searches were carried out in five electronic databases, with terms related to PFOA, including muscle strength, volume and activation. Only studies with at least one group with symptomatic PFOA and one asymptomatic group were included. The methodological quality of the studies was assessed using the Downs and Black checklist. Certainty of evidence was assessed using the GRADE methodology. Using the random effects model, a meta-analysis was performed when there were at least two studies reporting the same domain.

RESULTS

Eight studies (250 participants) met the inclusion criteria. Subjects with PFOA had weaker hip abduction (SMD -0.96; 95%CI = -1.34 to -0.57), hip external rotation (-0.55;-1.07 to -0.03), hip extension (-0.72;-1.16 to -0.28), and knee extension (-0.97;-1.41 to -0.53) when compared to asymptomatic controls. People with PFOA also presented with smaller volumes of the gluteus medius, gluteus minimus, tensor fascia lata, vastus medialis (VM), vastus lateralis (VL) and rectus femoris when compared to asymptomatic controls. Also, people with PFOA presented with changes in muscle activation for the VL, VM and gluteus maximus (GMax) when compared to asymptomatic controls.

CONCLUSION

People with PFOA present with lower strength and volume of the hip and quadriceps muscles and altered muscle activation of the VM, VL and GMax during ascending and descending stairs when compared to asymptomatic controls. However, the certainty of these findings are very low.

TRIAL REGISTRATION NUMBER

PROSPERO systematic review protocol (ID = CRD42020197776).

Quadriceps muscle volume has no effect on patellofemoral cartilage lesions in patients with end-stage knee osteoarthritis

PURPOSE

The quadriceps muscle has a positive effect on anterior knee pain. However, its effect on the patellofemoral (PF) cartilage in patients with end-stage knee osteoarthritis is unknown. The present study aimed to evaluate whether the quadriceps muscle area had a positive effect on the PF cartilage and whether this muscle had a positive effect on the clinical scores.

MATERIALS AND METHODS

Patients with confirmed cartilage status and clinical scores who underwent total knee arthroplasty (TKA) were included. The PF cartilage status was evaluated during TKA. The thickness and the area of the quadriceps muscle were measured using a knee computed tomography scan obtained before the surgery. The Q-angle, hip-knee-ankle angle, alignment, and Insall-Salvati ratio were measured by radiography.

RESULTS

Altogether, 204 patients were included in the study. Logistic regression was performed including factors associated with PF cartilage lesions. The regression model was found to be statistically significant (Hosmer-Lemeshow test, χ² = 0.493). A smaller hip-knee-ankle (HKA) angle was associated with a higher incidence of PF cartilage lesions (p = 0.033) and only the alignment had an effect on the PF cartilage lesions. PF cartilage lesions did not correlate with the clinical scores. A thicker medial portion of the quadriceps muscle was associated with a significantly higher Knee Society Knee Score (KSKS) (p = 0.028).

CONCLUSIONS

Quadriceps muscle thickness and area, Q-angle, and patellar height were not associated with PF cartilage lesions, while a smaller HKA angle was associated with PF cartilage lesions. The presence of PF cartilage lesions did not affect the clinical symptoms. However, a thicker medial portion of the quadriceps muscle was associated with a higher KSKS.

Relationship between individual forces of each quadriceps head during low-load knee extension and cartilage thickness and knee pain in women with knee osteoarthritis

BACKGROUND

This study aimed to clarify the individual forces of each quadriceps head during low-load contractions and to determine the associations between individual muscle force and cartilage thickness and symptoms in female knee osteoarthritis patients.

METHODS

Twenty-two women with painful knee osteoarthritis and 15 asymptomatic age-matched women (control group) participated in this cross-sectional study. Maximal knee extension strength and the cross-sectional area of each quadriceps muscle were measured. Shear modulus was calculated for each muscle during 20-Nm torque production by shear-wave elastography. Muscle force index was defined as the product of the cross-sectional area and shear modulus. Medial femur cartilage thickness was measured using an ultrasound B-mode image. Knee pain during gait was evaluated using a Numerical Rating Scale. Muscle force index, cross-sectional area, and maximal knee extension strength, which were defined as muscle functions, were compared between groups using the unpaired t-test. Correlation coefficients were calculated using muscle function, cartilage thickness, or pain.

FINDINGS

Maximal strength and vastus lateralis force index were smaller in the knee osteoarthritis group than in the control group (p < 0.001 and p = 0.005, respectively). In the knee osteoarthritis group, vastus medialis and vastus lateralis force indexes were positively correlated with cartilage thickness (r = 0.57 and r = 0.45, respectively), whereas the rectus femoris force index was negatively correlated with cartilage thickness (r = -0.45). The vastus lateralis force index was negatively correlated with knee pain (ρ = -0.56).

INTERPRETATION

Vasti force indices were positively associated with cartilage thickness; however, rectus femoris index was negatively associated in female patients with knee osteoarthritis.

A Review of the Relationships Between Knee Pain and Movement Neuromechanics

CONTEXT

Knee injury and disease are common, debilitating, and expensive. Pain is a chief symptom of knee injury and disease and likely contributes to arthrogenic muscle inhibition. Joint pain alters isolated motor function, muscular strength, and movement biomechanics. Because knee pain influences biomechanics, it likely also influences long-term knee joint health.

OBJECTIVE

The purpose of this article is 2-fold: (1) review effects of knee pain on lower-extremity muscular activation and corresponding biomechanics and (2) consider potential implications of neuromechanical alterations associated with knee pain for long-term knee joint health. Experimental knee pain is emphasized because it has been used to mimic clinical knee pain and clarify independent effects of knee pain. Three common sources of clinical knee pain are also discussed: patellofemoral pain, anterior cruciate ligament injury and reconstruction, and knee osteoarthritis.

DATA SOURCES

The PubMed, Web of Science, and SPORTDiscus databases were searched for articles relating to the purpose of this article.

CONCLUSION

Researchers have consistently reported that knee pain alters neuromuscular activation, often in the form of inhibition that likely occurs via voluntary and involuntary neural pathways. The effects of knee pain on quadriceps activation have been studied extensively. Knee pain decreases voluntary and involuntary quadriceps activation and strength and alters the biomechanics of various movement tasks. If allowed to persist, these neuromechanical alterations might change the response of articular cartilage to joint loads during movement and detrimentally affect long-term knee joint health. Physical rehabilitation professionals should consider neuromechanical effects of knee pain when treating knee injury and disease. Resolution of joint pain can likely help to restore normal movement neuromechanics and potentially improve long-term knee joint health and should be a top priority.

Does Gender Influence Outcome in Cartilage Repair Surgery? An Analysis of 4,968 Consecutive Patients from the German Cartilage Registry (Knorpel Register DGOU)

The goal was to examine gender differences of patient characteristics and outcome after cartilage repair based on a collective of nearly 5,000 patients. Patient characteristics, accompanying therapies, and outcome (Knee Injury and Osteoarthritis Outcome Score [KOOS], reoperations, patient satisfaction) of 4,986 patients of the German cartilage register DGOU were assessed by t test for possible gender differences. P values <0.05 were considered statistically significant. Women were older than men (38.07 ± 12.54 vs. 26.94 ± 12.394 years, P = 0.002), more often preoperated (0.30 ± 0.63 vs. 0.24 ± 0.55, P = 0.001), and had a longer symptom duration (25.22 ± 41.20 vs. 20.67 ± 35.32 months, P < 0.001). Men had greater mean leg axis malalignment than women (3.24° ± 3.26° vs. 2.67° ± 3.06°, P < 0.001), less favorable meniscal status (P = 0.001), worse defect stage (P = 0.006), and a more severely damaged corresponding articular surface (P = 0.042). At baseline (59.84 ± 17.49 vs. 52.10 ± 17.77, P < 0.001), after 6 months (72.83 ± 15.56 vs. 66.56 ± 17.66, P < 0.001), after 12 months (77.88 ± 15.95 vs. 73.07 ± 18.12, P < 0.001), and after 24 months (79.311 ± 15.94 vs. 74.39 ± 18.81, P < 0.001), men had better absolute KOOS values, but women had better relative KOOS increases 6 months (14.59 ± 17.31 vs. 12.49 ± 16.3, P = 0.005) as well as 12 months postoperatively (20.27 ± 18.6 vs. 17.34 ± 17.79, P = 0.001) compared with preoperatively, although 12 and 24 months postoperatively they were subjectively less satisfied with the outcome (P < 0.001) and had a higher reintervention rate at 24 months (0.17 ± 0.38 vs. 0.12 ± 0.33, P = 0.008). In summary, the present work shows specific gender differences in terms of patient characteristics, defect etiology, defect localization, concomitant therapy, and the choice of cartilage repair procedure. Unexpectedly, contrary to the established scientific opinion, it could be demonstrated that women show relatively better postoperative KOOS increases, despite a higher revision rate and higher subjective dissatisfaction.

Cartilage Biomarkers Coll2-1 and Coll2-1NO2 Are Associated with Knee OA MRI Features and Are Helpful in Identifying Patients at Risk of Disease Worsening

OBJECTIVE

To assess the cross-sectional association between serum levels of Coll2-1 and Coll2-1NO2, two cartilage degradation biomarkers; the burden of magnetic resonance imaging (MRI) features and clinical outcomes; and to evaluate the predictive value of these biomarkers on progression.

DESIGN

A total of 121 subjects with knee osteoarthritis (OA) were followed during 1 year with pain, function, and MRI assessment (PRODIGE study). Type II collagen-specific biomarker Coll2-1 and its nitrated form Coll2-1NO2 were directly measured in serum using immunoassays at baseline and after 3-, 6-, and 12-month follow-up.

RESULTS

Serum Coll2-1 and Coll2-1NO2 were correlated with several baseline knee features quantified with Whole-Organ Magnetic Resonance Imaging Score (WORMS). Coll2-1 was significantly correlated with periarticular cysts/bursitis (ρ = 0.29, P < 0.01), subarticular bone attrition (ρ = 0.25, P = 0.01), subarticular cysts (ρ = 0.24, P = 0.02), and articular cartilage integrity (ρ = 0.23, P = 0.03) WORMS subscores for the whole joint as well as with the medial femorotibial joint sum score (ρ = 0.26, P = 0.01) and medial femorotibial joint cartilage (ρ = 0.23, P = 0.02). Coll2-1NO2 correlated with WORMS total score (ρ = 0.23, P = 0.02), WORMS scores in the patellofemoral (ρ = 0.23, P = 0.02) and medial femorotibial compartments (ρ = 0.21, P = 0.03), with osteophytes scores (ρ = 0.27, P < 0.01), subarticular cysts (ρ = 0.24, P = 0.019), and intraarticular loose bodies (ρ = 0.27, P = 0.007). Baseline Coll2-1NO2 was higher in subjects with a pain worsening (426.4 pg/mL [278.04-566.95]) as compared to non-progressors (306.84 pg/mL [200.37-427.84]) over 1 year (AUC = 0.655, P = 0.015).

CONCLUSION

Serum cartilage biomarkers Coll2-1 and Coll2-1NO2 are associated with several knee OA features quantified with WORMS. Our study also shows that the baseline value of Coll2-1NO2 is positively associated with pain worsening.

Serum uric acid and knee osteoarthritis in community residents without gout: a longitudinal study

OBJECTIVES

Emerging evidence suggests a potential link between OA and gout; however, the association between serum uric acid (UA) itself and knee OA remains uncertain due to a lack of longitudinal studies. Here, we investigated the association between serum UA and knee OA according to cartilage status in elderly community residents without gout.

METHODS

In this longitudinal study, participants without a history of gout were recruited from among the Korean cohort of the Hallym Aging Study (n = 296 for radiography study and n = 223 for MRI study). Weight-bearing knee radiographs and 1.5-T MRI scans, along with blood collection for analysis of serum UA, were performed at baseline and after 3 years. The severity and structural progression of knee OA were evaluated using the Kellgren-Lawrence grading system and the Whole-Organ MRI Score (WORMS) cartilage scoring method. Multivariable logistic regression analysis was conducted using generalized estimating equation (GEE) models.

RESULTS

Serum UA levels were not associated with radiographic progression after adjusting for age, sex and BMI. There was no significant association between serum UA and tibiofemoral cartilage loss on MRI. However, baseline serum UA levels were negatively associated with patellofemoral cartilage loss over 3 years (adjusted odd ratio 0.70 per 1 mg/dl increase, 95% CI: 0.49, 0.98).

CONCLUSION

In this population-based cohort, serum UA was not a risk factor for knee OA progression. Further large-scale longitudinal studies in other populations are needed to validate the effects of UA on cartilage damage.

Impaired muscle capacity of the hip and knee in individuals with isolated patellofemoral osteoarthritis: a cross-sectional study

AIMS

The aims of this study were to compare the capacity of the knee and hip muscles between individuals with and without isolated patellofemoral osteoarthritis (PFOA) and to evaluate the impact of PFOA on pain, stiffness, and physical function.

METHODS

This cross-sectional study evaluated muscle capacity of the hip and knee using an isokinetic dynamometer. The isokinetic variables used in the statistical analysis were peak torque, total work, and average power. Pain, stiffness, and physical function were assessed using questionnaires.

RESULTS

A total of 26 individuals participated in the study (13 with PFOA and 13 controls). The PFOA group exhibited lower peak torque, total work, and average power for knee extension and flexion in the concentric mode (p ⩽ 0.01) as well as lower peak torque and total work for knee extension (p ⩽ 0.005) and lower total work for knee flexion (p = 0.05) in the eccentric mode. The PFOA group exhibited lower peak torque of the extensor, abductor, adductor, and internal rotator muscles of the hip (p ⩽ 0.05), less total work of the abductor and adductor muscles (p ⩽ 0.04), and lower average power of eccentric adduction of the hip (p = 0.01) compared with the healthy controls. Compared with the control group, the PFOA group had a higher level of pain, stiffness, and compromised physical functioning self-reported (p ⩽ 0.005).

CONCLUSION

Participants with PFOA exhibited impairments regarding muscle capacity of the hip and knee, higher level of pain and stiffness as well as compromised physical functioning in comparison with healthy controls.

Effect of photobiomodulation in the patellofemoral pain syndrome; randomized clinical trial in young women

OBJECTIVE

patellofemoral pain syndrome (PFPS) is one of the most frequent musculoskeletal disorders in the knee joint, affecting mainly physically active adolescents and young adults; its main symptom is pain. Physiotherapy has several therapeutic modalities aimed at pain relief, among which are photobiomodulation (PBM). The aim of the study was to analyze the effects of using PBM in cluster form (Laser + LED) in patients with PFPS.

PATIENTS AND METHODS

This study is characterized as quantitative, experimental, randomized, composed of 30 women with PFPS, randomized into two groups: Control Group (CG) and PBM Group (PBMG). Both groups underwent three evaluations: pre-intervention, post-intervention, and after one month of follow-up. Participants of the PBMG were presented to the application of the cluster device, three times a week, for four weeks. The intensity of spontaneous pain and movement were evaluated, knee function tests and function questionnaires. The results showed a reduction in pain only for the landing of the jump. As for the other variables there was no interaction of factors; the questionnaires used showed larger effect sizes for PBMG when compared to CG. It is possible to conclude that the use of PBM showed benefit in reducing pain at the time of landing of the jump and functional assessment questionnaires.

Exercise-therapy and education for individuals one year after anterior cruciate ligament reconstruction: a pilot randomised controlled trial

BACKGROUND

Guided rehabilitation beyond 6-months is rare following anterior cruciate ligament reconstruction (ACLR), despite high prevalence of unacceptable symptoms and quality of life (QoL). Our primary aim was to determine the feasibility of a randomised controlled trial (RCT) evaluating a physiotherapist-guided intervention for individuals 1-year post-ACLR with persistent symptoms. Our secondary aim was to determine if a worthwhile treatment effect could be observed for the lower-limb focussed intervention (compared to the trunk-focussed intervention), for improvement in knee-related QoL, symptoms, and function.

DESIGN

Participant- and assessor-blinded, pilot feasibility RCT.

METHODS

Participant eligibility criteria: i) 12-15 months post-ACLR; ii) < 87.5/100 on the Knee injury and Osteoarthritis Outcome Score (KOOS) QoL subscale; and either a one-leg rise test < 22 repetitions, single-hop < 90% limb symmetry; or Anterior Knee Pain Scale < 87/100. Participants were randomised to lower-limb or trunk-focussed focussed exercise and education. Both interventions involved 8 face-to-face physiotherapy sessions over 16-weeks. Feasibility was assessed by eligibility rate (> 1 in 3 screened), recruitment rate (> 4 participants/month), retention (< 20% drop-out), physiotherapy attendance and unsupervised exercise adherence (> 80%). Between-group differences for knee-related QoL (KOOS-QoL, ACL-QoL), symptoms (KOOS-Pain, KOOS-Symptoms), and function (KOOS-Sport, functional performance tests) were used to verify that the worthwhile effect (greater than the minimal detectable change for each measure) was contained within the 95% confidence interval.

RESULTS

47% of those screened were eligible, and 27 participants (3 participants/month; 48% men, 34±12 years) were randomised. Two did not commence treatment, and two were lost to follow-up (16% drop-out). Physiotherapy attendance was > 80% for both groups but reported adherence to unsupervised exercise was low (< 55%). Both interventions had potentially worthwhile effects for KOOS-QoL and ACL-QoL, while the lower-limb focussed intervention had potentially greater effects for KOOS-Sport, KOOS-Pain, and functional performance.

CONCLUSIONS

A larger-scale RCT is warranted. All feasibility criteria were met, or reasonable recommendations could be made to achieve the criteria in future trials. Strategies to increase recruitment rate and exercise adherence are required. The potential worthwhile effects for knee-related QoL, symptoms, and function indicates a fully-powered RCT may detect a clinically meaningful effect.

TRIAL REGISTRATION

Prospectively registered ( ACTRN12616000564459 ).

Bcl-xL expression following articular cartilage injury and its effects on the biological function of chondrocytes

This study aimed to investigate the expression of B-cell lymphoma-extra large (Bcl-xL) in cartilage tissues following articular cartilage injury and to determine its effects on the biological function of chondrocytes. A total of 25 necrotic cartilage tissue samples and 25 normal tissue samples were collected from patients diagnosed with osteoarthritis at our hospital from December 2015 to December 2018. The mRNA expression levels of Bcl-xL, caspase-3, and matrix metalloproteinase-3 (MMP-3) in the normal and necrotic tissues were examined via quantitative polymerase chain reaction, and their protein expression levels were detected via western blotting. The expression levels of Bcl-xL, insulin-like growth factor-1 (IGF-1), and bone morphogenetic protein (BMP) were significantly lower but those of caspase-3, MMP-3, interleukin-1β (IL-1β), and chemokine-like factor 1 (CKLF1) levels were markedly higher in necrotic cartilage tissues than in normal tissues. Following cell transfection, the expression levels of Bcl-xL, IGF-1, and BMP were remarkably higher but those of caspase-3, MMP-3, IL-1β, and CKLF1 were notably lower in the Si-Bcl-xL group than in the NC group. The Si-Bcl-xL group showed significantly lower cell growth and noticeably higher apoptosis rate than the NC group (normal control group). The expression of Bcl-xL is reduced following articular cartilage injury, and this reduction promotes the proliferation and inhibits the apoptosis of chondrocytes. Therefore, Bcl-xL could serve as a relevant molecular target in the clinical practice of osteoarthritis and other diseases causing cartilage damage.

Is patellofemoral pain preventable? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of interventions to reduce the risk of incident patellofemoral pain.

DESIGN

Systematic review and meta-analysis, with strength of evidence evaluated separately for each intervention type.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials evaluating the effectiveness of interventions to reduce patellofemoral pain risk compared with a control/non-exposed group.

RESULTS

Thirteen trials of mostly military recruits and young athletes analysed six different interventions. There was low certainty evidence from two trials (227 participants) that patellofemoral braces worn during physical activity (compared with no brace) effectively reduced the risk of patellofemoral pain (risk ratio (RR) 0.40, 95% CI 0.22 to 0.73; I2=24.0%). There was low certainty evidence from one trial (320 participants) that running technique retraining to (run softer) reduced patellofemoral pain risk (RR 0.21, 95% CI 0.07 to 0.60). There was low certainty evidence from four trials (3364 participants) that multicomponent (strengthening/neuromuscular) exercise programmes did not significantly reduce the risk of patellofemoral pain (RR 0.49, 95% CI 0.18 to 1.36; I2=64.9%), although broad CIs may reflect exercise dose variations among studies. There was very low certainty evidence from four trials (2314 participants) that foot orthoses (compared with flat inserts/no orthosis) did not significantly reduce the risk of patellofemoral pain (RR 0.63, 95% CI 0.35 to 1.13; I2=0.0%). Static stretching and a running programme that progressed intensity (compared with volume) did not significantly influence patellofemoral pain risk (single studies).

CONCLUSION

There is low-level evidence that patellofemoral braces and running technique retraining can reduce the risk of patellofemoral pain by 60%-79%.

Setting up distinctive outcome measures for each osteoarthritis phenotype

Osteoarthritis (OA) is an evolving chronic joint disease with a huge global impact. Given the intricate nature of the etiopathogenesis and subsequent high heterogeneity in the clinical course of OA, it is crucial to discriminate between etiopathogenic endotypes and clinical phenotypes, especially in the early stages of the disease. In this sense, we propose that an OA phenotype should be properly assessed with a set of outcome measures including those specifically related to the main underlying pathophysiological mechanisms. Thus, each OA phenotype can be related to different and clinically meaningful outcomes. OA phenotyping would lead to an adequate patient stratification in well-designed clinical trials and the discovery of precise therapeutic approaches. A significant effort will be required in this field in light of inconclusive results of clinical trials of tissue-targeting agents for the treatment of OA.

Influence of Antagonistic Hamstring Coactivation on Measurement of Quadriceps Strength in Older Adults

BACKGROUND

There is limited understanding of how antagonist muscle coactivation relates to measurement of strength in both individuals with and without knee osteoarthritis (KOA).

OBJECTIVE

This study sought to determine whether hamstring coactivation during a maximal quadriceps activation task attenuates net quadriceps strength.

DESIGN

Cross-sectional cohort analysis was conducted using data from the 60-month visit of the Multicenter Osteoarthritis Study (MOST).

SETTING

Laboratory.

PARTICIPANTS

A sample of 2328 community-dwelling MOST participants between the ages of 55 and 84 years, with or at elevated risk for KOA, completed the 60-month MOST follow-up visit. Of these, 1666 met inclusion criteria for the current study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Quadriceps strength; percentage of combined hamstring coactivation (HC), medial HC, and lateral HC. Quadriceps and hamstring strength were assessed using an isokinetic dynamometer. Surface electromyography was used to assess muscle activation patterns. General linear models, adjusted for age, BMI, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Kellgren-Lawrence (KL) grade and study site, modeled the relationship between antagonist hamstring coactivation and quadriceps strength.

RESULTS

Men had significantly greater quadriceps strength (P < .001), history of knee injury (P < .001) and surgery (P = .002), and greater presence of varus malalignment (P < .001). Women had greater pain (P < .001) and proportion of KL grade ≥2 (P = .017). Gender-specific analyses revealed combined HC (P = .013) and lateral HC inversely associated with quadriceps strength in women (P = .023) but not in men (combined HC P = .320, lateral HC P = .755). A nonlinear association was detected between quadriceps strength and medial HC. Assessment of quartiles of medial HC revealed the third quartile had reduced quadriceps strength when compared to the lowest quartile of coactivation in both men and women.

CONCLUSIONS

Hamstring coactivation attenuates measured quadriceps strength in women with or at elevated risk for KOA.

LEVEL OF EVIDENCE

II.

Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression

Background

Not meeting functional performance criteria increases reinjury risk after ACL reconstruction (ACLR), but the implications for osteoarthritis are not well known.

Objective

To determine if poor functional performance post-ACLR is associated with risk of worsening early osteoarthritis features, knee symptoms, function and quality of life (QoL).

Methods

Seventy-eight participants (48 men) aged 28±15 years completed a functional performance test battery (three hop tests, one-leg-rise) 1 year post-ACLR. Poor functional performance was defined as <90% limb symmetry index (LSI) on each test. At 1 and 5 years, MRI, Knee injury Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective form were completed. Primary outcomes were: (i) worsening patellofemoral and tibiofemoral MRI-osteoarthritis features (cartilage, bone marrow lesions (BMLs) and meniscus) and (ii) change in KOOS and IKDC scores, between 1 and 5 years.

Results

Only 14 (18%) passed (≥90% LSI on all tests) the functional test battery. Poor functional performance on the battery (all four tests <90% LSI) 1 year post-ACLR was associated with 3.66 times (95% CI 1.12 to 12.01) greater risk of worsening patellofemoral BMLs. A triple-crossover hop <90% LSI was associated with 2.09 (95% CI 1.15 to 3.81) times greater risk of worsening patellofemoral cartilage. There was generally no association between functional performance and tibiofemoral MRI-osteoarthritis features, or KOOS/IKDC scores.

Conclusion

Only one in five participants met common functional performance criteria (≥90% LSI all four tests) 1 year post-ACLR. Poor function on all four tests was associated with a 3.66 times increased risk of worsening patellofemoral BMLs, and generally not associated with decline in self-reported outcomes.